Provider Demographics
NPI:1982251427
Name:RUSSO, MICHAEL (LMHC, NCC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:LMHC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17042 PUNTLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46062-6521
Mailing Address - Country:US
Mailing Address - Phone:317-439-9530
Mailing Address - Fax:
Practice Address - Street 1:17042 PUNTLEDGE DR
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46062-6521
Practice Address - Country:US
Practice Address - Phone:317-439-9530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39003593A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health